Associate (primera)

Roles and Responsibilities

Job Summary

The role involves coordinating and transmitting clinical documentation to insurance payors to facilitate authorization approvals for medical services. A key responsibility is the accurate and timely faxing of patient clinical records along with the corresponding Utilization Review (UR) summaries to designated payors in accordance with established guidelines and payer-specific requirements.

This position requires thorough attention to detail to ensure that all clinical information, including physician notes, diagnostic reports, treatment plans, and supporting medical records, is complete, accurate, and properly organized prior to submission. The UR summary must clearly justify the medical necessity of the requested service, aligning with payor criteria to support approval decisions. Ensuring compliance with confidentiality standards and data protection regulations while handling sensitive patient information is a critical component of the role.

The individual is responsible for verifying payor authorization requirements, identifying missing or incomplete documentation, and coordinating with clinical teams, case managers, or utilization review staff to resolve discrepancies before submission. Timely follow-up on faxed submissions is essential to confirm receipt, address any requests for additional information, and prevent delays in authorization decisions that could impact patient care.

Maintaining accurate records of all fax transmissions, including dates, times, confirmation receipts, and authorization statuses, is required for tracking and audit purposes. The role may also involve responding to payor inquiries, resubmitting documentation when necessary, and escalating issues related to denials or delays to the appropriate internal teams.

Strong organizational and communication skills are essential, as the role serves as a link between healthcare providers and insurance payors. Familiarity with utilization review processes, medical terminology, and authorization workflows enhances effectiveness in ensuring approvals are obtained efficiently. Overall, this role plays a vital part in supporting continuity of care by ensuring that required authorizations are secured promptly and accurately through proper submission of clinical documentation and UR summaries.

Minimum Criteria :

B.Pharm, M.Parm, B.Sc life sciences